BACKGROUND/RATIONALE:
Stroke is the leading cause of death worldwide and the fourth leading cause of death in the United States. In North America, approximately 5 million people have had a stroke and 550,000 new cases occur each year. For Veterans admitted to the hospital, approximately 6,000 are diagnosed yearly as having had a stroke and another 5,000 with TIA (OQP and STROKE QUERI National Report 2009). For those who survive a stroke or a TIA 1 in 5 will suffer another stroke within 5 years.

Hypertension is a known modifiable risk factor for the development of a primary stroke or TIA and continues to be a risk factor for secondary prevention of stroke/TIA. For every 20 mm Hg increase in systolic blood pressure or 10 mm Hg increase in diastolic blood pressure, stroke mortality doubles. The recommended elements of care for patients with TIA and stroke have been well described in the American Heart Association/American Stroke Association guideline and endorsed by the American Academy of Neurology. One major component of care is intensive hypertension treatment and ongoing management with antihypertensive medications. While guidelines and recommendations for the control of blood pressure (BP) in patients after TIA/stroke are readily available, strategies to facilitate prescriber and patient adherence to recommended treatments are needed.

OBJECTIVE(S):
This RRP will give us key insights into the various communication challenges posed during transitions of care for post-stroke patients with continuing hypertension. It will also give us pilot data about the feasibility of academic detailing as an intervention approach. If we find, for example, that the length and intensity of exposure to academic detailing raises awareness but does not translate into behavior change we will experiment with other types of coaching models such as the longitudinal model that was successfully implemented using the Four Habits intervention. Likewise, if we find that the majority of challenges are at the organizational rather than the individual level, we will explore the use of policies, practices and incentives in addition to person to person efforts to implement PACT. In a subsequent SDP or IIR we anticipate being able to study the effect of the academic detailing intervention on actual hypertension outcomes. We plan to study clinicians' orientations toward patients and toward one another to better understand the underlying dynamics of the PACT model and how they might be modified to improve care. Since this is largely a hypothesis generating study we anticipate that our next step will be to test our results in an experimental or quasi-experimental design.

METHODS:
In Aim 1, we will use semi-structured "voice of the customer" interviews with key stakeholders to identify communication barriers in the transitions from hospital to home and home to primary care visits for inpatient and primary care clinicians, post TIA/stroke patients with continuing hypertension and their caregivers. Interviews will be conducted with patients/caregivers 7-14 days post discharge and then again after the first follow-up primary care visit to determine their understanding of hypertension control after discharge and whether they are following discharge instructions for their hypertension medication.

In Aim 2, we will use a brief (15-30 minute) academic detailing session for inpatient and primary care clinicians. We will then test the feasibility of using academic detailing to deliver these materials to clinicians. We will follow up with a brief questionnaire to the clinicians who received the academic detailing to determine the perceived usefullness and effectiveness of the approach.

FINDINGS/RESULTS:
We have completed enrolling Providers and Patients into the study and analyzing the Voice of the Customer Interviews. We are now set to meet with the Inpatient Residents (November 19, 2014) and will use a brief (15-30 minute) academic detailing session to deliver a mnemonic, ATTUNED, that is based on our voice of the customer interviews and is designed to facilitate the inpatien to outpatien transfer of care. We will follow up with a brief questionnaire to the clinicians who received the academic detailing to determine the perceived usefulness and effectiveness of the approach. We will modify as appropriate for the receiving outpatient physicians in their clinics.

Data analysis is completed and a manuscript based on our findings is under review at BMJ Quality and Safety.

IMPACT:
Results from this study indicate that additional training targeting discharge communication for patients with stroke/TIA is needed and can be improved using the mnemonic ATTUNED.